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WAL-MART PHARMACY 10-1506
CAH161312-04 GUTTENBERG MUNICIPAL HOSPITAL
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Covered Entity Details
Entity Name
GUTTENBERG MUNICIPAL HOSPITAL
Subdivision Name
Guttenberg General Surgery Practice Clinic
Type
Critical Access Hospital
340B ID
CAH161312-04
Entity Address
200 MAIN ST
GUTTENBERG, IA 52052-9108
Medicare Provider Number
161312
Outpatient Facility Provider Number
Participating Start Date
1/1/2019
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1506
Pharmacy Address
1220 WEST MAIN
MANCHESTER, IA 52057
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lisa Manson, Director of Ambulatory Services
(563) 252-1121
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2019
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